ED observation cuts CT use in kids with minor head trauma

For children with minor blunt head trauma, a period of observation in the emergency department (ED) is associated with reduced CT use without risking a delay in diagnosing traumatic brain injury, according to a study published online Aug. 2 in Annals of Emergency Medicine.

Moreover, the longer the observation period, the less likely a CT scan will be used, reported Deborah Schonfeld, MD, of Boston Children’s Hospital, and colleagues.

“In fact, every hour of ED observation reduced rate of CT use by 70 percent on average after adjustment for other patient and provider factors,” they wrote.

The findings were based a prospective cohort study of 1,381 children with blunt head trauma and a Glasgow Coma Scale score of 14 or higher. Schonfeld and colleagues broke down the effect of ED observation on CT utilization for children in the low-risk, intermediate-risk and high-risk categories of the Pediatric Emergency Care Applied Research Network Traumatic Brain Injury risk groups.

Of the patients enrolled in the study, 49 percent had a period of observation in the ED and 20 percent underwent CT scanning. Longer observation time was associated with reduced CT use in all three risk groups, with the-high risk, intermediate-risk and low-risk children demonstrating adjusted odds ratios of 0.11, 0.28 and 0.47, respectively.

“Clinical observation before the decision to obtain a CT allows clinicians to selectively image only children whose symptoms evolve or fail to improve,” wrote the authors. “The American Academy of Pediatrics has long recognized the role of an observation period in the management of children with minor blunt head trauma, and children with a significant traumatic brain injury rarely have a delayed diagnosis.”

All eight children in the current study who had a significant traumatic brain injury had an immediate CT.

While previous studies have shown an association between an observation period and a decline in CT utilization, Schonfeld and colleagues wrote that their study was the first to associate duration of the observation period with gradually declining odds of CT use.  

“Evidence-based guidelines for the care of children with minor blunt head trauma should include ED observation as a management strategy, particularly for those children at intermediate risk of traumatic brain injury,” wrote the authors.